LETTERS TO THE EDITOR
Extradural Haematoma in Football The Editor, Sir,
Extradural haematoma is a collection of blood between the inner table of the skull and the outer layer of dura mater. The main aetiologies are road traffic accident, fall and assault. It is rare in football. The most common playing action that causes head trauma is heading duel (1). We present the case of a 22-year old student who presented unconscious six hours after a heading duel in a football match. He fell down and lost consciousness. He regained consciousness after some minutes. A few hours later, he started having headache then became drowsy and lost consciousness. He had a small scalp swelling on the left fronto-temporal area. His Glasgow Coma Score was 8/15. He had anisocoria with left pupil 6 mm and right 3 mm and both pupils reacted sluggishly to light. There was right facial nerve palsy (upper motor), right hemiparesis with associated hypertonia and hyperreflexia. Clinical diagnosis of extradural haematoma was made and confirmed by computed tomography (CT) scan (Fig. 1) done three days after the incident. He had craniotomy (Fig. 2), and there was linear skull fracture over the haematoma. He did well and was discharged 13 days after surgery. There was no neurological deficit two months after the surgery.
Fig. 2:
Intraoperative photograph showing the haematoma being evacuated.
Extradural haematoma constitutes 0.5% of all head injured patients (2) and sports injuries constitute 2.7% of head injuries (3), thus showing rarity of extradural haematoma in sports. Bruzzone et al (4) reported a case of a 19-year old footballer who hit his fronto-parietal region against the left frontal scalp of his opponent. He fell down and lost consciousness for 20–30 minutes. Computed tomography scan done eight hours after the incident revealed right frontal extradural haematoma. He had emergency craniotomy and was discharged on the 10th day with no neurological deficit. The index patient travelled 170 km to do the CT scan because there was none in our city, causing delay in his treatment. His complete recovery gives credence to the outcome in patients with extradural haematoma associated with skull fracture in which the fracture serves as vent (5). Extradural haematoma in football should be suspected when there is loss of consciousness with lucid interval arising from heading duel. Football authorities should take into consideration the available medical facilities when planning to locate football stadiums. Keywords: Computed tomography, extradural haematoma, head trauma
Fig. 1:
Brain computed tomography scan showing left frontal extradural haematoma.
West Indian Med J 2015; 64 (3): 309
MON Nnadi1, OB Bankole2, SO Arigbabu2 From: 1Division of Neurosurgery, Department of Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria and 2Neurosurgical Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria. DOI: 10.7727/wimj.2013.311
310
Letters
Correspondence: Dr M Nnadi, Division of Neurosurgery, Department of Surgery, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria. E-mail: nnadimon@ yahoo.com REFERENCES
1.
2.
3.
4.
5.
Andersen TE, Árnason Á, Engebretsen L, Bahr R. Mechanisms of head injuries in elite football. Br J Sports Med 2004; 38: 690−6. Narayan RK. Closed head injuries. In: Rengachary SS, Wilkins HR, eds. Principles of neurosurgery. London: Wolfe Publishing; 1994: 16.2–16.5. Lindsay KW, Mclatchie G, Jennet B. Serious head injury in sports. Inj Prev 1980; 281: 789−91. Bruzzone E, Cocoti L, Pisani R. Intracranial delayed epidural haematoma in a soccer player. A case report. Am J Sports Med 2000; 28: 901−3. Chan K, Mann KS, Yue CP, Fan YW, Chueg M. The significance of skull fractures in acute traumatic intracranial haematoma in adolescents: a prospective study. J Neurosurg 1990; 72: 189−94.
The Significance of Evaluating the Variation of Mechanical Microstructure for Hypertrophic Cardiomyopathy Using Diffusion Tensor Magnetic Resonance Imaging
The Editor, Sir,
Hypertrophic cardiomyopathy (HCM) is a genetic and familial cardiovascular disease which can cause severe arrhythmia and heart failure. With irregular hypertrophy and disorganized arrangement of cardiomyocytes on histological picture, the normal myocardium macrostructure appears in whole or part as ventricular wall thickness, especially ventricular septal thickness (1). The variation of myocardial microstructures is associated with a range of clinical outcomes. However, common examinations such as echocardiography and delayed enhancement magnetic resonance (DE-MR) can only diagnose HCM after cardiac dysfunction and macro structural changes. Although histology is the gold standard for HCM, it is unable to quantify changes and display 3D spatial structure. Therefore, highly sensitive and ultra-early examination techniques are in urgent need for the diagnosis of HCM. Based on anisotropy of water molecules movement in different tissues, diffusion tensor imaging (DTI) can be used to quantify the diffusion characterization of internal water molecules in tissues (2). In the clinical setting, DTI is widely used in tractography of the central nervous system. Intrinsically, DTI is a multi-parametric method to quantify myocardial fibres by means of multiple aspects, such as orientations using primary eigenvector, mechanical function using helix angle (HA) and transmural angle (TA), diffusion characteristic using fractional anisotropy (FA) and apparent diffusion coefficient (ADC). Recently, DTI has been applied to trace myocardial fibre of animal heart in vitro. Healy et al found that the range of helix angle and transmural angle through the left ventricle was significantly different among species (3). Their results proved West Indian Med J 2015; 64 (3): 310
the sensitivity of DTI to explore variation of microstructures in myocardial fibres and laid the foundation for further studies. Despite great challenges of DTI for in vivo heart due to cardiac motion, Toussaint et al successfully reconstructed the architecture of myocardial fibre in healthy volunteers in vivo (4). Wei et al also developed a multi-modal approach to assess the effects of cardiac motion on the human heart by diffusion tensor parameters. Their research is impressive and encouraging for improving imaging methods and evaluating myocardial fibres in vivo (5). We propose that DTI is a sensitive method to diagnose the micro alternations of myocardial fibre in hypertrophic cardiomyopathy before occurrence of severe clinical symptoms or cardiac dysfunction in non-invasive and quantitative measurement. Three-dimension myocardial fibre architecture and corresponding quantitative parameters of patients will be revealed by DTI for in vivo heart in the very near future. This technique enables dynamic observation of patients and longterm follow-up to detect lesions promptly. Combining mechanical method with molecular imaging, DTI has excellent ability to solve clinical problems and achieve translational medicine. Diffusion tensor imaging, an essential examination method, will have extensive application in clinical diagnosis to benefit more patients with HCM in future. ACKNOWLEDGMENTS This study was supported by The National Natural Science Foundation of China (81100027). There are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. Keywords: Diffusion tensor imaging, hypertrophic cardiomyopathy
Q Fan1, 2, Y Wang2, F Gao2, Y Guo1 From: 1Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China and 2Molecular Imaging Center, Department of Radiology, West China Hospital, Sichuan University, Chengdu, China. Correspondence: Dr Y Guo, Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China or Dr F Gao, Molecular Imaging Laboratory, Department of Radiology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu 610041, China. Fax: +86 951 6744423; e-mail: [email protected] REFERENCES 1.
DOI: 10.7727/wimj.2014.238
Wolf CM, Moskowitz IP, Arno S, Branco DM. Somatic events modify hypertrophic cardiomyopathy pathology and link hypertrophy to arrhythmia. Proc Natl Acad Sci 2005; 102: 18123–8.
Extradural Haematoma in Football The Editor, Sir,
Extradural haematoma is a collection of blood between the inner table of the skull and the outer layer of dura mater. The main aetiologies are road traffic accident, fall and assault. It is rare in football. The most common playing action that causes head trauma is heading duel (1). We present the case of a 22-year old student who presented unconscious six hours after a heading duel in a football match. He fell down and lost consciousness. He regained consciousness after some minutes. A few hours later, he started having headache then became drowsy and lost consciousness. He had a small scalp swelling on the left fronto-temporal area. His Glasgow Coma Score was 8/15. He had anisocoria with left pupil 6 mm and right 3 mm and both pupils reacted sluggishly to light. There was right facial nerve palsy (upper motor), right hemiparesis with associated hypertonia and hyperreflexia. Clinical diagnosis of extradural haematoma was made and confirmed by computed tomography (CT) scan (Fig. 1) done three days after the incident. He had craniotomy (Fig. 2), and there was linear skull fracture over the haematoma. He did well and was discharged 13 days after surgery. There was no neurological deficit two months after the surgery.
Fig. 2:
Intraoperative photograph showing the haematoma being evacuated.
Extradural haematoma constitutes 0.5% of all head injured patients (2) and sports injuries constitute 2.7% of head injuries (3), thus showing rarity of extradural haematoma in sports. Bruzzone et al (4) reported a case of a 19-year old footballer who hit his fronto-parietal region against the left frontal scalp of his opponent. He fell down and lost consciousness for 20–30 minutes. Computed tomography scan done eight hours after the incident revealed right frontal extradural haematoma. He had emergency craniotomy and was discharged on the 10th day with no neurological deficit. The index patient travelled 170 km to do the CT scan because there was none in our city, causing delay in his treatment. His complete recovery gives credence to the outcome in patients with extradural haematoma associated with skull fracture in which the fracture serves as vent (5). Extradural haematoma in football should be suspected when there is loss of consciousness with lucid interval arising from heading duel. Football authorities should take into consideration the available medical facilities when planning to locate football stadiums. Keywords: Computed tomography, extradural haematoma, head trauma
Fig. 1:
Brain computed tomography scan showing left frontal extradural haematoma.
West Indian Med J 2015; 64 (3): 309
MON Nnadi1, OB Bankole2, SO Arigbabu2 From: 1Division of Neurosurgery, Department of Surgery, University of Calabar Teaching Hospital, Calabar, Nigeria and 2Neurosurgical Unit, Department of Surgery, Lagos University Teaching Hospital, Idi-Araba, Lagos, Nigeria. DOI: 10.7727/wimj.2013.311
310
Letters
Correspondence: Dr M Nnadi, Division of Neurosurgery, Department of Surgery, University of Calabar Teaching Hospital, Calabar, Cross River State, Nigeria. E-mail: nnadimon@ yahoo.com REFERENCES
1.
2.
3.
4.
5.
Andersen TE, Árnason Á, Engebretsen L, Bahr R. Mechanisms of head injuries in elite football. Br J Sports Med 2004; 38: 690−6. Narayan RK. Closed head injuries. In: Rengachary SS, Wilkins HR, eds. Principles of neurosurgery. London: Wolfe Publishing; 1994: 16.2–16.5. Lindsay KW, Mclatchie G, Jennet B. Serious head injury in sports. Inj Prev 1980; 281: 789−91. Bruzzone E, Cocoti L, Pisani R. Intracranial delayed epidural haematoma in a soccer player. A case report. Am J Sports Med 2000; 28: 901−3. Chan K, Mann KS, Yue CP, Fan YW, Chueg M. The significance of skull fractures in acute traumatic intracranial haematoma in adolescents: a prospective study. J Neurosurg 1990; 72: 189−94.
The Significance of Evaluating the Variation of Mechanical Microstructure for Hypertrophic Cardiomyopathy Using Diffusion Tensor Magnetic Resonance Imaging
The Editor, Sir,
Hypertrophic cardiomyopathy (HCM) is a genetic and familial cardiovascular disease which can cause severe arrhythmia and heart failure. With irregular hypertrophy and disorganized arrangement of cardiomyocytes on histological picture, the normal myocardium macrostructure appears in whole or part as ventricular wall thickness, especially ventricular septal thickness (1). The variation of myocardial microstructures is associated with a range of clinical outcomes. However, common examinations such as echocardiography and delayed enhancement magnetic resonance (DE-MR) can only diagnose HCM after cardiac dysfunction and macro structural changes. Although histology is the gold standard for HCM, it is unable to quantify changes and display 3D spatial structure. Therefore, highly sensitive and ultra-early examination techniques are in urgent need for the diagnosis of HCM. Based on anisotropy of water molecules movement in different tissues, diffusion tensor imaging (DTI) can be used to quantify the diffusion characterization of internal water molecules in tissues (2). In the clinical setting, DTI is widely used in tractography of the central nervous system. Intrinsically, DTI is a multi-parametric method to quantify myocardial fibres by means of multiple aspects, such as orientations using primary eigenvector, mechanical function using helix angle (HA) and transmural angle (TA), diffusion characteristic using fractional anisotropy (FA) and apparent diffusion coefficient (ADC). Recently, DTI has been applied to trace myocardial fibre of animal heart in vitro. Healy et al found that the range of helix angle and transmural angle through the left ventricle was significantly different among species (3). Their results proved West Indian Med J 2015; 64 (3): 310
the sensitivity of DTI to explore variation of microstructures in myocardial fibres and laid the foundation for further studies. Despite great challenges of DTI for in vivo heart due to cardiac motion, Toussaint et al successfully reconstructed the architecture of myocardial fibre in healthy volunteers in vivo (4). Wei et al also developed a multi-modal approach to assess the effects of cardiac motion on the human heart by diffusion tensor parameters. Their research is impressive and encouraging for improving imaging methods and evaluating myocardial fibres in vivo (5). We propose that DTI is a sensitive method to diagnose the micro alternations of myocardial fibre in hypertrophic cardiomyopathy before occurrence of severe clinical symptoms or cardiac dysfunction in non-invasive and quantitative measurement. Three-dimension myocardial fibre architecture and corresponding quantitative parameters of patients will be revealed by DTI for in vivo heart in the very near future. This technique enables dynamic observation of patients and longterm follow-up to detect lesions promptly. Combining mechanical method with molecular imaging, DTI has excellent ability to solve clinical problems and achieve translational medicine. Diffusion tensor imaging, an essential examination method, will have extensive application in clinical diagnosis to benefit more patients with HCM in future. ACKNOWLEDGMENTS This study was supported by The National Natural Science Foundation of China (81100027). There are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. Keywords: Diffusion tensor imaging, hypertrophic cardiomyopathy
Q Fan1, 2, Y Wang2, F Gao2, Y Guo1 From: 1Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan, China and 2Molecular Imaging Center, Department of Radiology, West China Hospital, Sichuan University, Chengdu, China. Correspondence: Dr Y Guo, Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China or Dr F Gao, Molecular Imaging Laboratory, Department of Radiology, West China Hospital, Sichuan University, No. 37, Guo Xue Xiang, Chengdu 610041, China. Fax: +86 951 6744423; e-mail: [email protected] REFERENCES 1.
DOI: 10.7727/wimj.2014.238
Wolf CM, Moskowitz IP, Arno S, Branco DM. Somatic events modify hypertrophic cardiomyopathy pathology and link hypertrophy to arrhythmia. Proc Natl Acad Sci 2005; 102: 18123–8.
